1 / 43

Clostridium difficile (CDI) Infections Toolkit Activity C: ELC Prevention Collaboratives

Clostridium difficile (CDI) Infections Toolkit Activity C: ELC Prevention Collaboratives. Carolyn Gould, MD MSCR Cliff McDonald, MD, FACP Division of Healthcare Quality Promotion Centers for Disease Control and Prevention.

hadassah
Download Presentation

Clostridium difficile (CDI) Infections Toolkit Activity C: ELC Prevention Collaboratives

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clostridium difficile (CDI)Infections ToolkitActivity C: ELC Prevention Collaboratives Carolyn Gould, MD MSCR Cliff McDonald, MD, FACP Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Last reviewed - 2/29/12 --- Disclaimer: The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

  2. Outline • Background • Impact • HHS Prevention Targets • Pathogenesis • Epidemiology • Prevention Strategies • Core • Supplemental • Measurement • Process • Outcome • Tools for Implementation/Resources/References

  3. Background: ImpactAge-Adjusted Death Rate* for Enterocolitis Due to C. difficile, 1999–2006 2.5 Male Female 2.0 White Black Entire US population 1.5 Rate 1.0 0.5 0 1999 2000 2001 2002 2003 2004 2005 2006 Year *Per 100,000 US standard population Heron et al. Natl Vital Stat Rep 2009;57(14). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

  4. Background: HHS Prevention Targets • Case rate per 10,000 patient-days as measured in NHSN • National 5-Year Prevention Target: 30% reduction • Because little baseline infection data exists, administrative data for ICD-9-CM coded C. difficile hospital discharges is also tracked • National 5-Year Prevention Target: 30% reduction http://www.hhs.gov/ophs/initiatives/hai/prevtargets.html

  5. Background: Pathogenesis of CDI 1. Ingestion of spores transmitted from other patients via the hands of healthcare personnel and environment 3. Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon 4. Toxin A & B Production leads to colon damage +/- pseudomembrane 2. Germination into growing (vegetative) form Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.

  6. Background: EpidemiologyCurrent epidemic strain of C. difficile • BI/NAP1/027, toxinotype III • Historically uncommon – epidemic since 2000 • More resistant to fluoroquinolones • Higher MICs compared to historic strains and current non-BI/NAP1 strains • More virulent • Increased toxin A and B production • Polymorphisms in binding domain of toxin B • Increased sporulation McDonald et al. N Engl J Med. 2005;353:2433-41. Warny et al.Lancet. 2005;366:1079-84. Stabler et al. J Med Micro. 2008;57:771–5. Akerlund et al. J Clin Microbiol. 2008;46:1530–3.

  7. Background: EpidemiologyRisk Factors • Antimicrobial exposure • Acquisition of C. difficile • Advanced age • Underlying illness • Immunosuppression • Tube feeds • ? Gastric acid suppression Main modifiable risk factors

  8. Core Strategies High levels of scientific evidence Demonstrated feasibility Supplemental Strategies Some scientific evidence Variable levels of feasibility Prevention Strategies *The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac

  9. Prevention Strategies: Core • Implement an antimicrobial stewardship program • Contact Precautions for duration of diarrhea • Hand hygiene in compliance with CDC/WHO • Cleaning and disinfection of equipment and environment • Laboratory-based alert system for immediate notification of positive test results • Educate about CDI: HCP, housekeeping, administration, patients, families http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.

  10. Prevention Strategies: Supplemental • Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* • Presumptive isolation for symptomatic patients pending confirmation of CDI • Evaluate and optimize testing for CDI • Implement soap and water for hand hygiene before exiting room of a patient with CDI • Implement universal glove use on units with high CDI rates* • Use sodium hypochlorite (bleach) – containing agents for environmental cleaning * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

  11. Supplemental Prevention Strategies: Rationale for considering extending isolation beyond duration of diarrhea Bobulsky et al. Clin Infect Dis 2008;46:447-50.

  12. Supplemental Prevention Strategies: Consider presumptive isolation for patients with > 3 unformed stools within 24 hours • Patients with CDI may contaminate environment and hands of healthcare personnel pending results of diagnostic testing • CDI responsible for only ~30-40% of hospital-onset diarrhea • However, CDI more likely among patients with >3 unformed (i.e. taking the shape of a container) stools within 24 hours • Send specimen for testing and presumptively isolate patient pending results • Positive predictive value of testing will also be optimized if focused on patients with >3 unformed stools within 24 hours • Exception: patient with possible recurrent CDI (isolate and test following first unformed stool)

  13. Supplemental Prevention Strategies: Evaluate and optimize test-ordering practices and diagnostic methods • Most laboratories have relied on Toxin A/B enzyme immunoassays • Low sensitivities (70-80%) lead to low negative predictive value • Despite high specificity, poor test ordering practices (i.e. testing formed stool or repeat testing in negative patients) may lead to many false positives • Consider more sensitive diagnostic paradigms but apply these more judiciously across the patient population • Employ a highly sensitive screen with confirmatory test or a PCR-based molecular assay • Restrict testing to unformed stool only • Focus testing on patients with > 3 unformed stools within 24 hours • Require expert consultation for repeat testing within 5 days Peterson et al. Ann Intern Med 2009;15:176-9.

  14. Supplemental Prevention Strategies: Hand Hygiene – Soap vs. Alcohol gel • Alcohol not effective in eradicating C. difficile spores • However, one hospital study found that from 2000-2003, despite increasing use of alcohol hand rub, there was no concomitant increase in CDI rates • Discouraging alcohol gel use may undermine overall hand hygiene program with untoward consequences for HAIs in general Boyce et al. Infect Control Hosp Epidemiol2006;27:479-83.

  15. Supplemental Prevention Strategies: Hand Washing: Product Comparison * Only value that was statistically better than others Conclusion: Spores may be difficult to eradicate even with hand washing. Edmonds, et al. Presented at: SHEA 2009; Abstract 43.

  16. Supplemental Prevention Strategies: Hand Hygiene Methods Since spores may be difficult to remove from hands even with hand washing, adherence to glove use, and Contact Precautions in general, should be emphasized for preventing C. difficile transmission via the hands of healthcare personnel Johnson et al. Am J Med 1990;88:137-40.

  17. Supplemental Prevention Strategies: Glove Use Rationale for considering universal glove use (in addition to Contact Precautions for patients with known CDI) on units with high CDI rates • Although the magnitude of their contribution is uncertain, asymptomatic carriers have a role in transmission • Practical screening tests are not available • There may be a role for universal glove use as a special approach to reducing transmission on units with longer lengths of stay and high endemic CDI rates • Focus enhanced environmental cleaning strategies and avoid shared medical equipment on such units as well

  18. Supplemental Prevention Strategies: Environmental Cleaning • Bleach can kill spores, whereas other standard disinfectants cannot • Limited data suggest cleaning with bleach (1:10 dilution prepared fresh daily) reduces C. difficile transmission • Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates • Therefore, bleach may be most effective in reducing burden where CDI is highly endemic Mayfield et al. Clin Infect Dis 2000;31:995-1000. Wilcox et al. J Hosp Infect 2003;54:109-14.

  19. Supplemental Prevention Strategies: Environmental Cleaning Assess adequacy of cleaning before changing to new cleaning product such as bleach • Ensure that environmental cleaning is adequate and high-touch surfaces are not being overlooked • One study using a fluorescent environmental marker to asses cleaning showed: • only 47% of high-touch surfaces in 3 hospitals were cleaned • sustained improvement in cleaning of all objects, especially in previously poorly cleaned objects, following educational interventions with the environmental services staff • The use of environmental markers is a promising method to improve cleaning in hospitals. Carling et al. Clin Infect Dis 2006;42:385-8.

  20. Contact Precautions for duration of illness Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system CDI surveillance Education Prolonged duration of Contact Precautions* Presumptive isolation Evaluate and optimize testing Soap and water for HH upon exiting CDI room Universal glove use on units with high CDI rates* Bleach for environmental disinfection Antimicrobial stewardship program Summary of Prevention Measures Core Measures Supplemental Measures * Not included in CDC/HICPAC 2007 Guideline for Isolation Precautions

  21. Measurement: Process Measures • Core Measures: • Measure compliance with CDC/WHO recommendations for hand hygiene and Contact Precautions • Assess adherence to protocols and adequacy of environmental cleaning • Supplemental Measures: • Intensify assessment of compliance with process measures • Track use of antibiotics associated with CDI in a facility

  22. Measurement: OutcomeCategorize Cases by location and time of onset† Admission Discharge < 4weeks 4-12weeks > 12weeks 2 d HO CO-HCFA Indeterminate CA-CDI * Day 1 Day 4 Time HO: Hospital (Healthcare)-Onset CO-HCFA: Community-Onset , Healthcare Facility-Associated CA: Community -Associated *Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CA † Onset defined in NHSN LabID Event by specimen collection date Modified from CDAD Surveillance Working Group.Infect Control Hosp Epidemiol2007;28:140-5.

  23. Measurement: OutcomeUse NHSN CDAD Module

  24. Measurement: Outcome Focus on Laboratory Identified (LabID) Events in NHSN

  25. Measurement: OutcomeNHSN Reporting: Definitions Based on data submitted to NHSN, CDI LabID Events are categorized as: • Incident: specimen obtained >8 weeks after the most recent LabID Event • Recurrent: specimen obtained >2 weeks and ≤ 8 weeks after most recent LabID Event

  26. Measurement: OutcomeNHSN Reporting: Definitions Incident cases further characterized based on date of admission and date of specimen collection: • Healthcare Facility-Onset (HO): LabID Event collected >3 days after admission to facility (i.e., on or after day 4) • Community-Onset (CO): LabID Event collected as an outpatient or an inpatient ≤3 days after admission to the facility (i.e., days 1, 2, or 3 of admission) • Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility ≤4 weeks prior to date stool specimen collected

  27. Measurement: OutcomeCalculating CDI Incidence Rates* • Healthcare Facility-Onset Incidence Rate = Number of all Incident HO CDI LabID Events per patient per month / Number of patient days for the facility x 10,000 • Combined Incidence Rate = Number of all Incident HO and CO-HCFA CDI LabID Events per patient per month / Number of patient days for the facility x 10,000 *For a given healthcare facility

  28. Evaluation Considerations • Assess baseline policies and procedures • Areas to consider • Surveillance • Prevention strategies • Measurement of effect of strategies • Coordinator should track new policies/practices implemented during collaboration

  29. References • Dubberke ER, Butler AM, Reske KA, et al. attributable outcomes of endemic Clostridium difficile-associated disease in nonsurgical patients. Emerg Infect Dis 2008;14:1031-8. • Dubberke ER, Reske KA, Olssen MA, et al. Short- and long term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clin Infect Dis 2008:46:497-504. • Edmonds S, Kasper D, Zepka C, et al. Clostridium difficile and hand hygiene: spore removal effectiveness of handwash products. Presented at: SHEA 2009; Abstract 43.

  30. References • Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf • Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007;59:990-5. • Heron MP, Hoyert DLm Murphy SL, et al. Natl Vital Stat Rep 2009;57(14). US Dept of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

  31. References • Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88:137-40. • Mayfield JL, Leet T, Miller J, et al. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31:995–1000. • McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene–variant strain of Clostridium difficile. N Engl J Med. 2005;353:2433-41.

  32. References • McDonald LC, Coignard B, Dubberke E, et al. Ad Hoc CDAD Surveillance Working Group. Recommendations for surveillance of Clostridium difficile-associated disease.Infect Control Hosp Epidemiol 2007; 28:140-5. • Oughton MT, Loo VG, Dendukuri N, et al.Hand hygiene with soap and water is superior to alcohol rum and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol2009; 30:939-44. • Peterson LR, Robicsek A. Does my patient have Clostridium difficile infection? Ann Intern Med 2009;15:176-9 • Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992–8.

  33. References • SHEA/IDSA Compendium of Recommendations. Infect Control Hosp Epidemiol 2008;29:S81–S92. http://www.journals.uchicago.edu/doi/full/10.1086/591065 • Stabler RA, Dawson LF, Phua LT, et al. Comparitive analysis of BI/NAP1/027 hypervirulent strains reveals novel toxin B-encoding gene (tcdB) sequences. J Med Micro. 2008;57:771–5. • Sunenshine RH, McDonald LC. Clostridium difficile-associated disease: new challenges from and established pathogen. Cleve Clin J Med. 2006;73:187-97.

  34. References • Warny M, Pepin J, Fang A, Killgore G, et al. Toxin production by and emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet. 2005;366:1079-84. • Wilcox MF, Fawley WN, Wigglesworth N, et al. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003:54:109-14.

  35. Additional resources CDI Checklist Example SHEA/IDSA Compendium of Recommendations Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92. Abbett SK et al.Infect Control Hosp Epidemiol2009;30:1062-9.

  36. Additional Reference Slides • The following slides may be used for presentations regarding CDI. • Explanations are available in the notes section of the slides.

  37. Supplemental Prevention Strategies: Rationale for Soap and Water: Lack of efficacy of alcohol-based handrub against C. difficile Oughton et al.Infect Control Hosp Epidemiol2009;30:939-44.

  38. Supplemental Prevention Strategies: Hand Hygiene – Alcohol Hand Rub Use 2000-2003 Boyce et al. Infect Control Hosp Epidemiol2006; 27:479-83.

  39. Supplemental Prevention Strategies: Hand Hygiene – CDI Rates 2000-2003 Boyce JM et al. Infect Control Hosp Epidemiol2006; 27:479-83.

  40. Supplemental Prevention Strategies: UniversalGlove Use Role of asymptomatic carriers?Rationale for universal glove use on units with high CDI rates Riggs et al. Clin Infect Dis2007;45:992–8.

  41. Supplemental Prevention Strategies: Environmental Cleaning How Much Can be Achieved via Environmental Decontamination? Mayfield et al. Clin Infect Dis 2000;31:995–1000.

  42. Supplemental Prevention Strategies:Environmental CleaningAssess adequacy of cleaning before changing to new cleaning product Carling et al. Clin Infect Dis 2006;42:385-8.

  43. Supplemental Prevention Strategies: Audit and feedback targeting broad-spectrum antibiotics Fowler et al. J Antimicrob Chemother 2007;59:990-5.

More Related